1. Comprehensive Program Review June 28, 2013
Community Strategies: Janet Kachadoorian’s Cluster Fitchburg, Leominster-Betanray, Leominster-Merriam, Templeton, Wendell and West Boylston
Meaningful Day is focused on a person-centered concept of structured activities.
Comprehensive Program Review June 28, 2013

2. CLUSTER HIGHLIGHTS
Created budget cuts for a 6 month period and adhered to them.
Three programs went through the QUEST audit and did an amazing job.  We had two QUEST audits on the same day, so Kelly had to do hers alone. Kelly completed the day alone and not only did well, she shined and made CRJ/CS look like rock stars. 
Participation in meaningful day has increased

3. CHALLENGES Creating a PICA free environment
PICA is eating disorder characterized by the craving and consumption of non-nutritive substances, such as clay, chalk, dirt, or sand. Although PICA is observed most frequently in children, it is the most common eating disorder in individuals with developmental disabilities.
Retaining staff in our behavioral homes
Employment for our individuals

4. STAFFING
Staff Turnover Rates
Performance Evaluations
Staff Training

5. STAFF TURNOVER RATES (5/1/2012 – 4/30/13)
The current CS Cluster average is 31.5% compared to the CSMA average of 24%
Last CPR, Cluster average was 27% vs. CSMA overall of 22% (December 2011 – November 2012)
Data obtained from HR Turnover Reports

6. STAFF OVERDUE PERFORMANCE EVALUATIONS
November April 2013
Overdue Evaluations
As of April 30, 2013 FT PT
Fitchburg 2
Leominster Betanray
Leominster Merriam
Templeton
Wendell
West Boylston
Cluster - Totals
 June
November 2012
Overdue Evaluations
As of November 30, 2012 FT PT
Fitchburg (opened 11/12)
Leominster Betanray
Leominster Merriam 1
Templeton
Wendell
West Boylston
Cluster - Totals 2
Total of 2 FTEs and 0 PTE overdue performance evaluations
Last CPR, a total of 2 FTEs and 0 PTE overdue performance evaluations
Data obtained from HR Department & HR Personnel Summary

7. STAFF TRAINING HOURS November 2012 – April 2013
Total of 2,075 training hours were completed
Average of 5.9 hours per staff per month
Average of 35.9 hours per staff/over six months per cluster; this is a 6.2% increase from the last CPR
E Training Hours
MMR Training Hours
Total
Fitchburg
43.75
597
640.75
Leominster Betanray
13.5
248
261.5
Leominster Merriam 57
361
418
Templeton
77.25
193
270.25
Wendell
30.25
306
336.25
West Boylston
40.25
108
148.25
Cluster
262
1,813
2075
Last CPR:
Total of training hours were completed
Average of 5.62 hours per staff per month
Average of 33.8 hours per staff/over six months per cluster
Data obtained from MMRs and HR Reports

8. CLIENT RELATED Clinical Hours Elopements (Walk-Aways) Medication
De-escalation and Restraints
Mainstream/Community
Inclusion Activities

9. CLINICAL HOURS November 2012 – April 2013
A total of clinical hours; the Cluster Average = 11.4 clinical hours per client/six-months or 1.9 hours per client per month. This is a 42.5% increase from the last CPR.
Last CPR, a total of 185 clinical hours; the cluster average was 8 clinical hours per client/over six- months or 1.3 hours per client per month.
Data obtained from MMRs

10. CLIENT ELOPEMENTS (WALK-AWAYS) November 2012 – April 2013 June 2012 –
Fitchburg
145
Leominster Betanray
Leominster Merriam 1
Templeton
Wendell
West Boylston
Cluster - Total 3
Please note: Fitchburg Residence – every time a resident steps outside of the residence (without permission) it is considered an elopement
Data obtained from MMRs

11. MEDICATION INCIDENTS & OCCURRENCES November 2012 - April 2013
Total of 14 medication incidents and occurrences
Last CPR, a total of 11 medication incidents and occurrences.
Data obtained from MMRs

12. DE-ESCALATIONS : RESTRAINTS
November 2012 – April 2013
June 2012 – November 2012
Fitchburg
4:1
0:0
Leominster Betanray
36:0
5:1
Leominster Merriam
20:1
38.6:1
Templeton
106:0
99:0
Wendell
23:1
15.5:1
West Boylston
24:0
2:1
Cluster Average
696 De-escalations: Restraints or 7:1
450 De-escalations:
14 Restraints or 32:1
This is a 224% increase in the overall de-escalation to restraint ratio from the last CPR
(55% increase in de-escalation and 721% increase in restraints)
Data obtained from MMRs

13. COMMUNITY INCLUSION This is a .28% decrease from the last CPR
Community Inclusion Activities Participated In and Offered (November 2012 – April 2013)
Average of 3.8 community inclusion activities per client/six months
This is a .28% decrease from the last CPR
Last CPR, average of 4.08 community inclusion activities participated in per client/six months
Data obtained from MMRs

14. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered (November 2012 – April 2013)
Average of 11.6 Mainstream Activities Participated in per client/six months
This is a 15% decrease from the last CPR
Last CPR, average of 13.4 mainstream activities participated in per client/six months
Data obtained from MMRs

15. KEY MMR RESULTS Employment/Education: ( As of April 30, 2013)
3 clients (10.3%) are employed or in a pre-vocational training program
20 out of 29 (69%) clients are in meaningful day
6 out of 29 (20.6%) clients are in a day program
Other:
29 out of 29 (100%) clients chose to participate in the healthy living options within their program
“0” contraband reported
31 site visits conducted by outside funders
Staff Certifications:
100% certified in PAC/CPI, First AID/CPR, Human Rights
82% of staff are MAP Certified ; this is a 1.4% decrease from the last CPR, (83.4% of staff were MAP certified)
Fitchburg Residence (67%); Leominster Betanray = 100%; Leominster Merriam = 80%; Templeton = 77%; West Boylston = 89%; Wendell = 80 %
Last CPR: Fitchburg Apt. (0%); Leominster Betanray = 67%; Leominster Merriam = 100%; Templeton = 83%; West Boylston = 80%; Wendell = 87%

16. KEY MMR RESULTS

17. CPR ACTION PLAN
See Handout